ATI RN
Psychiatric Emergencies Questions
Question 1 of 5
A male client in the mental health unit is guarded and vaguely answers the nurse's questions. He isolates in his room and sometimes opens the door to peek into the hall. Which problem can the RN anticipate?
Correct Answer: D
Rationale: The correct answer is D: Delusions of persecution. The client's behavior of being guarded, isolating, and peeking into the hall suggests paranoia and fear of being persecuted. This aligns with delusions of persecution, a common symptom seen in clients with mental health conditions like schizophrenia. Visual hallucinations (A) and auditory hallucinations (B) typically involve seeing or hearing things that are not there, which are not evident in the scenario. Excessive motor activity (C) does not fit the client's observed behavior of isolating in the room. Delusions of grandeur are not mentioned in the scenario, making option D the most suitable choice.
Question 2 of 5
An older male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement?
Correct Answer: D
Rationale: The correct answer is D: Assist the client to clean the walls. This action promotes therapeutic communication, maintains dignity, and encourages self-care. It allows the client to take responsibility for their actions and fosters a sense of autonomy. Choices A and B may be condescending and fail to address the behavior directly. Choice C may escalate the situation and jeopardize the therapeutic relationship.
Question 3 of 5
A client is admitted to the mental health unit and sits in the corner of the dayroom. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?
Correct Answer: A
Rationale: The correct action for the nurse to implement is to attempt to ask the client simple questions (Choice A). By asking simple questions, the nurse can start building rapport with the client and gradually gain their trust. This approach can help the client feel more comfortable and open up during the assessment interview. It is important for the nurse to demonstrate patience, empathy, and understanding towards the client's guarded and suspicious behavior. Postponing the client interview until the next day (Choice B) may not address the client's current needs and may lead to further distrust. Asking another nurse to talk with the client (Choice C) may not necessarily be effective as the client may benefit from continuity of care with the same nurse. Documenting the client's paranoid behavior (Choice D) is important for the client's medical record but should not be the only action taken by the nurse in this situation.
Question 4 of 5
A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first?
Correct Answer: C
Rationale: The correct answer is C: Take other clients in the area to the client lounge. This intervention prioritizes the safety and well-being of both the agitated client and other clients in the unit. By removing other clients from the potentially escalating situation, the nurse can prevent further agitation or harm. This intervention also allows the client some space and privacy to calm down without an audience, potentially reducing their agitation. Incorrect choices: A: Transport the client to the seclusion room - This is a restrictive measure and should only be used as a last resort for safety reasons. B: Quietly approach the client with additional staff members - Approaching an agitated client may escalate the situation, especially if the client is refusing medication. D: Administer medication to chemically restrain the client - Chemical restraint should only be used as a last resort and must follow specific protocols and guidelines. It should not be the first intervention attempted.
Question 5 of 5
Client treated with lithium for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take?
Correct Answer: A
Rationale: Step 1: The symptoms of diarrhea, vomiting, and drowsiness are potential signs of lithium toxicity. Step 2: Nurse should prioritize safety and inform the healthcare provider (HCP) immediately to adjust the treatment plan. Step 3: Delaying the next dose could prevent further toxicity and potential harm to the client. Step 4: Administering an antiemetic or encouraging fluids may not address the underlying issue of lithium toxicity. Step 5: Documenting the symptoms as expected side effects without taking immediate action could lead to serious consequences.